1
Clinical Intake Assessment, Part 1
Student Name
Clinical Mental Health Counseling, Walden University
COUN 6360: Assessment in Counseling and Education
Dr. Oberheim
March 21, 2021
, 2
Summary of Assessment Report
Demographic Information
Name: Mikayla Doe Phone: (555)555-5555
Address: Ethnicity: N/A
Date of Interview: 3/18/2021 Sex: Female
DOB: 02/13/2013 Name of Interviewer:
Age: 8 years old E-Mail Address:
Reason for Referral
Mikayla is an 8-year-old girl who has been referred to counseling for a clinical intake by
her school counselor, after breaking the classroom fish tank during quiet time. Mikayla is said to
get a long with her peers and is popular but has some behavioral issues in class. Mikayla
struggles to follow her teacher’s instructions, staying on task and remaining seated. Her teacher
says she is constantly in motions, shouts when she should talk quietly, and is easily distracted.
These behavioral issues have resulted in her repeating the second grade due to low test scores
and poor grades (Neukrug & Fawcett, 2015).
Family Background
Mikayla lives with both parent’s and her younger brother. Mikayla’s mother says she is “a
handful, but very sweet” (Neukrug & Fawcett, 2015).
Significant Medical/Counseling History
Mikayla was previously seeing the school counselor before being referred. Mikayla’s
current teacher had consulted with her kindergarten and first grade teachers to discuss some of
the issues she has in the classroom. Her teachers do not think Mikayla has communication issues
a specific learning disorder, as she performs above grade-level expectations in small groups or
Clinical Intake Assessment, Part 1
Student Name
Clinical Mental Health Counseling, Walden University
COUN 6360: Assessment in Counseling and Education
Dr. Oberheim
March 21, 2021
, 2
Summary of Assessment Report
Demographic Information
Name: Mikayla Doe Phone: (555)555-5555
Address: Ethnicity: N/A
Date of Interview: 3/18/2021 Sex: Female
DOB: 02/13/2013 Name of Interviewer:
Age: 8 years old E-Mail Address:
Reason for Referral
Mikayla is an 8-year-old girl who has been referred to counseling for a clinical intake by
her school counselor, after breaking the classroom fish tank during quiet time. Mikayla is said to
get a long with her peers and is popular but has some behavioral issues in class. Mikayla
struggles to follow her teacher’s instructions, staying on task and remaining seated. Her teacher
says she is constantly in motions, shouts when she should talk quietly, and is easily distracted.
These behavioral issues have resulted in her repeating the second grade due to low test scores
and poor grades (Neukrug & Fawcett, 2015).
Family Background
Mikayla lives with both parent’s and her younger brother. Mikayla’s mother says she is “a
handful, but very sweet” (Neukrug & Fawcett, 2015).
Significant Medical/Counseling History
Mikayla was previously seeing the school counselor before being referred. Mikayla’s
current teacher had consulted with her kindergarten and first grade teachers to discuss some of
the issues she has in the classroom. Her teachers do not think Mikayla has communication issues
a specific learning disorder, as she performs above grade-level expectations in small groups or
